Care homes face uphill struggle as new rules give them responsibility for oral health

Dentist leaders have welcomed the new questions being posed by inspectors – which ask homes to assess both their policies and access to dental services – but warned that support and resources are not yet in place to help homes provide dental care to their residents. 

NHS dentists across England now anticipate high demand for dental visits to meet the new standards but are unequipped to assist, owing to NHS England’s failure to commission dedicated services for residents. The BDA understands local authority funded oral health promotion teams will also struggle to meet new training needs, owing to sustained cuts to public health budgets.

Before 2006 NHS dentists in England could provide domiciliary care as a matter of routine. Since then, reform has left practitioners unable to make visits without a dedicated contract.

The recent CQC Smiling Matters report noted that one of the main challenges in providing access to NHS services was lack of domiciliary care provision. BDA analysis of Freedom of Information data suggests levels of commissioning are low and falling, equivalent to providing coverage to less than 1.3 per cent of the population whose activity is significantly limited by disability or ill health.

The report noted that 52 per cent of the homes it contacted did not even have an oral health plan for residents, and 47 per cent of staff never received training specific to dental care. 73 per cent of care plans only partly covered or did not cover oral health at all, with homes specialising in dementia less likely to do so. 

The BDA’s England Community Dental Services Chair, Charlotte Waite, said, “From today, care homes finally have a responsibility to protect the oral health of their residents. It’s not before time, but staff picking up the phone for help will find they have nowhere to go. 

“Health commissioners can’t keep pretending that hundreds of thousands of elderly residents don’t exist. We will keep seeing horrific cases of neglect until a plan and resources to ensure access and training are in place.

“Many care homes may well struggle come inspection time, but the main victims here are vulnerable residents. Officials must recognise their duty to attend to basic health needs.”

John Milne, National Professional Dental Advisor at the Care Quality Commission said, “Maintenance of good oral health is a vital factor in overall wellbeing, and we are sure that care homes will respond positively to meet the recommendations raised in our Smiling Matters report.

“We have already seen several good examples of how care home residents were helped to care for their mouths and look after their teeth. Access to dental care is clearly a challenge, and we hope that both commissioners and the profession will work together for the benefit of all”.

New mandatory questions, which will now form part of the ‘Effective’ measure in CQC reports.

1. Do all staff have training in oral health care?

• Is oral health covered in induction?
• Is oral health a mandatory component of regular training?
• Do staff feel confident in supporting oral health care?
• Do staff know what to look for to identify deterioration in oral health?
• Do staff consider poor oral health when assessing reasons behind weight loss, infection, or tissue viability?

2. How do you ensure oral health care is assessed, considered and delivered as a part of a person’s care plan?

• Is the service aware of the NICE Guideline NG48?
• Is oral health assessed fully on entry to the care home in line with this guideline?
• Is there a detailed oral health care plan in place?
• Do people have easy access to toothpaste, toothbrushes, denture cleaning fluid?
• Do people have access to routine and emergency dental care?

Freedom of information requests on domiciliary visits commissioned and provided in England, NHS England

Coverage estimates by the BDA. Public Health England has used 2011 census data covering the population with activity 'limited a lot' owing to health problems or disability as a proxy for calculating domiciliary dental care need. That amounted to 8.3 per cent of the population in 2011. Figures from 2015-18 are generated from ONS midyear population estimates and modelled against treatments delivered to produce coverage estimates.

Case Study: Patient C

Patient C: 93-year-old female. Patient was blind, with advanced dementia, had poor mobility and resided in a care home.

Patient C was brought in to Accident and Emergency by her daughter as dentures were stuck in the mouth.

When her daughter visited her at the care home she noticed that there was an unpleasant smell from her mouth and that her mother was not eating.

The daughter spoke to the carer who said they could not get the denture out of her mouth for the past week.

The daughter tried to contact a dentist to come to the home as the patient was unable to access her regular dentist. She was advised by the dentist to call the local community dental service but was told that the wait for a domiciliary visit was 8 weeks.

The daughter then took her mum to the local accident and emergency service.

The hospital did have an onsite dental service and she was seen by a dentist that day. The gums were inflamed and had grown over the metal clasps holding the lower denture in.

This denture had not been removed for a significant period (around a month). The denture needed to be surgically removed from the mouth under local anaesthetic. The denture was very unclean, and the gums underneath were inflamed and ulcerated.

The patient was discharged that day and the daughter reported a few days later that her mother had started eating again.

Key points:

• At some point the dentures were not removed from the mouth and this led to a very vulnerable adult suffering. A discussion with the patient's key worker raised the issue of a lack of training for care staff.
• There is also a need for an urgent dental service for patients like this that may involve domiciliary care.